The Review Panel, led by Lord Toby Harris and including forensic psychologist Professor Graham Towl, was set up by the Justice Secretary to consider self-inflicted deaths in custody amongst 18-24 year olds. ‘All self-inflicted deaths are a tragedy’, the Review website notes, ‘and we want to ensure those that occur whilst individuals are under the protection of the state are subject to the most thorough scrutiny.’

The report makes powerful reading, and Lord Harris writes evocatively and with obvious gratitude towards the families of the 87 young people whose cases were considered in detail. ‘Listening to the harrowing stories of families who have lost their loved one through a self-inflicted death in custody has been a humbling experience, and one that the panel and I will remember for a long time’, Lord Harris said. ‘Whatever the events that led to them ending up in custody, those young people were also someone’s son or daughter, sister or brother, partner or even parent.’ Sir Winston Churchill’s sentiment of 1910 is pushed to the fore: ‘there is a treasure, if you can only find it, in the heart of every man.’

As of 31 December 2014, 101 people under 24 have died in prisons since April 2007, another 14 since the cohort whose case studies were considered in detail for the report. ‘Each of those deaths represents a failure by the State to protect the young people concerned,’ chides the report. ‘That failure is all the greater because the same criticisms have occurred time and time again. Our findings echo the criticisms and recommendations made consistently and repeatedly throughout the last fifteen years and more. Lessons have not been learned and not enough has been done to bring about substantive change. This time, following this Review, it must be different.’

The report argues that prison is a hugely expensive intervention with questionable benefits, concluding that the experience of living in a prison or a Young Offender’s Institution is not conducive to rehabilitation. ‘Young adults do not have enough activities, such as education or work, which will enable them to live purposeful lives. Additionally, we heard frequent examples of medical and mental health appointments being missed because there are not sufficient staff available to escort the patient.’ It calls for ‘an inherent shift in the philosophy of prison in this country’ recommending that the Ministry of Justice publishes a new statement on the purposes of prison, where the primary purpose is rehabilitation, and which acknowledges that all persons deprived of their liberty shall be treated with respect for their human rights.

Individual cases do not make easy reading for anyone involved in the justice system. The inquest into the death of 16-year-old Joseph Scholes in Stoke Health Young Offender Institution in 2002 concluded that ‘risk was not properly recognised and appropriate precautions were not taken to prevent it’. Or, as Joseph’s note to his parents put it, ‘I tried telling them and they just don’t fucking listen’.

The report makes a number of concrete recommendations, including around safer cells, the importance of family contact and liaison, and the creation of a new specialist role focused on rehabilitation. ‘Delaying action until the resource position is easier is not an option,’ the report warns. ‘Unless progress is made on the proposals that we have made, young people will continue to die unnecessarily in our prisons and we will continue to waste countless millions of pounds in failing to rehabilitate those who could be rehabilitated, in locking up those for whom a non-prison option would be more appropriate, and in failing to intervene early enough to prevent people from entering the criminal justice system in the first place.’

Professor Graham Towl is Pro Vice Chancellor and Deputy Warden at Durham University. He is a Professor of forensic psychology and was formerly Chief Psychologist at the Ministry of Justice. He told us: ‘In public health terms prisoners are a vulnerable group on a range of measures with high needs for psychological support. I would encourage the National Offender Management Service to build on previous and existing work and employ a broader range of applied psychologists to deliver services reflecting the full range of the needs of members of the public who happen to be prisoner.’

We asked Lord Harris what his main message for psychologists was. He said: ‘The need for proper mental health support for prisoners came across loud and clear in the evidence we considered. It is important that when prisoners encounter psychologists in prison that they can feel confident that the psychologist is there to help them and will prioritise their well-being and safety. A kind and compassionate ear may well do much to save the lives of some of our most vulnerable citizens.’